Second Opinion: Doc Says Blue Cross Opioid Policy Is Flawed

Amidst concerns over a massive national increase in the use and abuse of prescription painkillers, health insurer Blue Cross Blue Shield of Massachusetts instituted a new policy to reduce pain medication addiction and misuse.

This week The Boston Globe reports that as a result of the new policy, Blue Cross has cut prescriptions of narcotic painkillers by an estimated 6.6 million pills in 18 months.

But Daniel P. Alford, MD, an associate professor of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program at Boston University School of Medicine and Boston Medical Center, calls the policy "flawed and irresponsible." Here's Alford's response:

By Dr. Daniel P. Alford
Guest Contributor

The Blue Cross Blue Shield of Massachusetts opioid management program was implemented to provide members with “appropriate pain care” and reduce the risk of opioid addiction and diversion.

In a recent Boston Globe report they claim “very significant success” with this program after 18 months because they have cut opioid prescriptions by 6.6 million pills.

Is this really a measure of success and if so, for whom? It likely saves Blue Cross money but has it successfully achieved their program's stated goals? Does decreased opioid prescribing mean more appropriate pain care? Does decreased opioid prescribing reduce the risk of addiction or diversion, or does it decrease access to a specific pain medication (opioids) for treating legitimate chronic pain? Is the observed decrease in opioid prescribing evidence that opioids have been overprescribed, as Blue Cross claims, or is it proof that instituting a barrier to opioid prescribing (prior authorization) will decrease prescribing even for legitimate need? Are patients with chronic pain really benefiting from this program? I doubt it.

Adding yet more paperwork for physicians will not improve pain care, decrease addiction or the numbers of accidental overdoses from prescription opioids. Those physicians who are unwilling (or ambivalent) to prescribe opioids even when indicated will use the prior authorization requirement as an excuse to continue not prescribing. Those who are overly liberal in prescribing will figure out the most efficient way to satisfy the insurance requirements for approvals. Physicians who responsibly prescribe opioids – that is, prescribing them only when the benefits outweigh any risks — will be saddled with more administrative burdens to justify their well thought-out treatment decisions.

Some physicians may ultimately decide that prescribing opioids isn’t worth the trouble despite known benefits for some patients.

Some physicians may become overwhelmed and burned out with the large number of desperate patients seeking a doctor willing to consider prescribing opioids for chronic pain.

The Blue Cross program ignores an important principle highlighted in the 2011 Institute of Medicine’s blueprint for transforming pain care in the US — chronic pain is a chronic disease. As opposed to acute pain — that is, a symptom that resolves — chronic pain persists and often gets worse over time. By requiring prior approvals to prescribe any opioid for more than 30 days, Blue Cross is assuming that chronic pain will resolve by 30 days. This is a false assumption.

As a primary care physician who manages a large number of patients suffering from chronic disabling pain, I appreciate the complexities of balancing appropriate pain management with the safe use of opioids. I understand the clinical challenges of the subjective determination of whether a patient on opioids is benefiting (i.e., improved pain control and function) or being harmed (i.e., addiction). In addition I understand the difficulties of distinguishing the patient who is inappropriately “drug seeking” due to addiction, from the patient who is appropriately pain-relief seeking, as they both can present as equally desperate for help.,

However, if Blue Cross were serious about improving my ability to manage chronic pain safely, they would increase access to new, yet more expensive, abuse-deterrent opioids (e.g., reformulated OxyContin, Opana and Embeda) rather than continuing to prefer (Tier 1) easily altered and abused opioids such as methadone and morphine.

I worry about this flawed and irresponsible policy, and that while Blue Cross congratulates itself on a job well done — decreasing the number prescriptions of opioids — we are swinging the pendulum unnecessarily too far back to the days of under-treating chronic pain in a patient population that is too often stigmatized and lacks a unified voice.